Healthcare Provider Details

I. General information

NPI: 1770762775
Provider Name (Legal Business Name): MARK W RAYBOULD, LISW, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2007
Last Update Date: 02/10/2024
Certification Date: 02/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2811 INDIAN SCHOOL RD NE
ALBUQUERQUE NM
87106-1825
US

IV. Provider business mailing address

2811 INDIAN SCHOOL RD NE
ALBUQUERQUE NM
87106-1825
US

V. Phone/Fax

Practice location:
  • Phone: 505-573-4044
  • Fax: 505-212-0975
Mailing address:
  • Phone: 505-573-4044
  • Fax: 505-212-0975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNM

VIII. Authorized Official

Name: MARK WILLIAM RAYBOULD
Title or Position: PRESIDENT/SOLE OWNER PROVIDER
Credential: LCSW
Phone: 505-573-4044